243

Conferences and Reviews

Total Hip Arthroplasty
Discussants
JORGE S. SIOPACK and HARRY E. JERGESEN, MD, San Francisco, California

Total hip arthroplasty, or surgical replacement of the hip joint with an artificial prosthesis, is a recon-
structive procedure that has improved the management of those diseases of the hip joint that have
responded poorly to conventional medical therapy. In this review we briefly summarize the evolu-
tion of total hip arthroplasty, the design and development of prosthetic hip components, and the
current clinical indications for this procedure. The possible complications of total hip arthroplasty,
its clinical performance over time, and future directions in hip replacement surgery are also dis-
cussed.
(Siopack JS, Jergesen HE: Total hip arthroplasty. West J Med 1995; 162:243-249)

T otal hip arthroplasty is an orthopedic procedure that
involves the surgical excision of the head and prox-
imal neck of the femur and removal of the acetabular
cartilage and subchondral bone. An artificial canal is
created in the proximal medullary region of the femur,
and a metal femoral prosthesis, composed of a stem and
small-diameter head, is inserted into the femoral
medullary canal. An acetabular component composed of
a high-molecular-weight polyethylene articulating sur-
face is inserted proximally into the enlarged acetabular
space (Figures 1 and 2). To yield successful results,
these total hip arthroplasty components must be fixed
firmly to the bone, either with polymethylmethacrylate
cement or, in more recent uncemented designs, by bony
ingrowth into a porous coating on the implant, resulting
in "biologic" fixation.
Total hip arthroplasty is currently one of the most
widely performed procedures in orthopedic practice in
the United States.* Since its introduction in this country
in 1969, it has proved remarkably successful in elimi-
nating pain and restoring function in hips severely
involved with diseases such as osteoarthritis. It is esti-
mated that about 170,000 total hip arthroplasties are per-
formed each year in this country and that about 300,000
are done worldwide.' The first total hip replacement is
thought to have been done in London by Phillip Wiles in
1938.2 The procedure was further developed in the
1 950s by pioneers such as McKee and Farrar.' This early
work laid the groundwork for the innovative studies of
Sir John Charnley who, in the late 1960s, approached
the problem of artificial hip joint design by using the
biomechanical principles of human hip joint function.4'-
Repeated trials and experimentation with various
*See also editorial by T. A. DeCoster, MD, and D. Rivero, MD, "Total Hip
Arthroplasty-A Cure?" on page 274 of this issue.
From the Department of Orthopaedic Surgery, University of Califomia, San Francisco (UCSF), School of Medicine, and the Department of Veterans Affairs
Medical Center (Dr Jergesen). Mr Siopack is a fourth-year medical student at UCSF.
Reprint requests to Harry E. Jergesen, MD, Dept of Orthopaedic Surgery, MU-320W, UCSF, San Francisco, CA 94143-0728.
materials and prosthetic designs culminated in the cre-
ation of the Charnley low-friction arthroplasty, a proce-
dure still considered by many to be the current standard
of total hip replacement. The noteworthy innovations of
Charnley's arthroplasty included the combination of a
small-diameter-22-mm-femoral head with a high-
density polyethylene acetabular component to reduce
friction and fixation of these prosthetic components to
bone with polymethylmethacrylate cement.
Since Charnley's original prosthesis was introduced,
several variants of the artificial hip joint have been
developed; none have proved to be superior in the clini-
cal setting, however. For example, despite the theoretical
advantage of a larger-diameter femoral head, which
some think permits more motion, generates less stress,
and dislocates less readily, the longevity of the Chamley
prosthesis appears to be enhanced by the smaller-
diameter head, which reduces friction and the amount of
wear debris produced and results in a lower incidence of
acetabular loosening.6
Revision total hip arthroplasty is carried out in
patients where there is failure of a previously implanted
prosthesis. In such cases, all cement and prosthetic com-
ponents are removed carefully to avoid penetrating or
fracturing the bone. New components are then implanted
and fixed with either a cemented or uncemented tech-
nique. Surgical indications for revision arthroplasty
include loosening of the prosthetic components, wear-
debris osteolysis, acute or chronic deep infection,
mechanical failure of the prosthetic components, and
chronic recurrent dislocation. Surgical revision is techni-
cally more difficult than the primary total hip arthroplas-
ty procedure, both because there is less bone stock to
work with and because the removal of adherent cement or
prosthetic components may result in fracture or perfora-
244 WJM, March 1995-Vol 162, No. 3
tion of the bone. With each successive total hip revision,
the risk of infection and symptomatic loosening may
increase substantially.2 The number of these procedures is
increasing steadily because many of the primary total hip
arthroplasties done in the 1970s are beginning to fail.
Improved operative techniques and specialized revision
prosthetic components are being developed to decrease
the morbidity associated with revision operations.
Indications and Goals
The most common condition for which total hip
arthroplasty is done is severe osteoarthritis of the hip,
accounting for 70% of cases. The primary indication for
this procedure is severe pain and the limitation in activ-
ities of daily living that it causes. To warrant doing total
hip replacement, pain must be refractory to conservative
measures such as oral nonsteroidal anti-inflammatory
medication, weight reduction, activity restriction, and
the use of supports such as a cane. It is generally pre-
ferred that total hip arthroplasty be done in patients older
than 60 years because at this age, the physical demands
on the prosthesis tend to be fewer and the longevity of
the operation approaches the life expectancy of the
patient. Other conditions for which the procedure may
be indicated and which predispose to the development of
secondary osteoarthritis include developmental dys-
plasia of the hip, Paget's disease, trauma, and
osteonecrosis of the femoral head. Patients with rheuma-
toid arthritis, other collagen diseases such as systemic
lupus erythematosus, and ankylosing spondylitis may
benefit as well. The large number of operations per-
formed each year reflects the fact that more than 90% of
appropriately selected patients achieve complete pain
relief and notable improvement in function.7
Despite this level of success, total hip arthroplasty
occasionally may be associated with complications.
Acetabulum
Head of femur
Shaft of femur
Figure 1.-Anatomy of a right hip shows the site of surgical
moval of the femoral neck in total hip arthroplasty.
Total Hip Arthroplasty-Siopack and jergesen
Figure 2.-A total hip arthroplasty with the use of methyl-
methacrylate cement to fix the prosthetic femoral and acetabu-
lar components to the bony structures is shown.
Patients may harbor unrealistic expectations of the
degree of activity the prosthesis will safely allow. In pre-
operative consultation, physicians must stress that the
primary goal of the operation is the relief of pain when
other options have failed. Motion may be improved, but
not in every patient. Most important, heavy repetitive
impact loading with activities such as running or jump-
ing may predispose the prosthesis to wear and loosening,
thus shortening its life span.
Biomechanics and Materials
During normal ambulation, the human hip undergoes
cyclic loading that can place forces three to five times
those of body weight on prosthetic components. During
more strenuous activity, such as running or climbing, the
joint is exposed to much greater forces-as much as 12
times those of body weight. Biomechanical analysis of
these forces has prompted design engineers to position
the prosthetic components to maximize support of the
implant throughout the walking cycle. In general,
implants are designed to closely approximate the func-
tion of the natural hip joint. Many considerations in
materials and manufacturing technology dictate design
requirements in prosthetic components that may limit
the achievement of this goal, however.
Most hip prostheses consist of an ultrahigh-molecular-
weight polyethylene acetabular cup and a metal-alloy
femoral component. In cemented techniques, polymethyl-
methacrylate cement is used to fix the femoral component
in bone, whereas in uncemented arthroplasties, the pros-
thesis interfaces with bone directly. In current practice,
acetabular components are rarely cemented, even if a sur-
geon chooses to fix the femoral component with cement.
Uncemented acetabular components are fixed to the
re- pelvis by bone ingrowth into an outer porous metal shell
that surrounds the polyethylene cup.
WJM, March 1995-Vol 162, No. 3
Acetabular Component
In the past decade, ultrahigh-molecular-weight poly-
ethylene has been introduced to replace high-density
polyethylene because of its superior resistance to wear.8
Before Charnley's work, metal acetabular cups were
used to articulate directly with metal femoral heads (as
in the McKee-Farrar and Ring prostheses). The draw-
back to this design was the high friction between the two
metal surfaces, resulting in wear and loosening of the
prosthesis due to high frictional torque. Although
Charnley's use of high-density polyethylene reduced
these problems considerably, the search for even more
wear-resistant, biocompatible materials continues.
Femoral Component
The primary goal in the manufacture of femoral
components is to ensure long-term biocompatibility and
high resistance to the repeated cyclical loads encoun-
tered during normal hip function. The most common
metals that have been used in the femoral component are
alloys of stainless steel, titanium, and cobalt-chrome.
Although cobalt-chrome designs have proved successful
for many years, titanium implants are also commonly
used. The proponents of titanium cite the fact that it is
the most biologically inert of these metals and that its
relatively low elastic modulus most closely resembles
that of femoral cortical bone.9
An innovation in the design of femoral components
has been the introduction of separate modular cobalt-
chrome heads that are fixed to the neck portion of the
femoral stem by interference fit. A choice of different
neck lengths in the head component permits accurate
adjustment of soft-tissue tension and leg length. Ceramic
has been introduced recently as an alternative material
for the femoral head component. In in vitro testing, cer-
tain ceramics demonstrate a substantially lower coeffi-
cient of friction against polyethylene compared with
cobalt-chrome alloys. In clinical practice, modular
ceramic head components fitted to metal femoral stems
have been used by some surgeons in place of cobalt-
chrome head components. The comparative long-term
efficacy of ceramic heads is not yet known, and some
concern has been expressed over the possibility of brit-
tle failure of ceramic components.
Cement
Polymethylmethacrylate cement is a self-curing
acrylic polymer without any adhesive properties. It is
used as a grouting agent to securely fix the prosthetic
components to bone. The polymer achieves fixation
through processes known as "microlocking" and
"macrolocking." During microlocking, the cement
squeezes into the interstices of the cancellous bone to
ensure fixation throughout the whole bone-cement inter-
face. In the process of macrolocking, the cement
enhances fixation by filling large irregular spaces within
the bone surrounding the implant.
Total Hip Arthroplasty-Siopack and jergesen 245
The technique of cement implantation has been of
great importance in assuring good long-term fixation.
Care is taken to ensure proper penetration of cement into
the bone and adequate filling of all empty spaces adja-
cent to the surface of the prosthesis. This is achieved by
introducing the cement under pressure. Either intraoper-
ative centrifugation or preparing the cement mixture in a
vacuum serves to remove air bubbles during the early
stages of polymerization. Bubbles that remain in the
cement once it has cured may act as weak spots, or stress
risers, that facilitate the propagation of cracks in the
cement mantle. In some circumstances, the cement is
impregnated with antibiotics to reduce the incidence of
postoperative infection. Not all surgeons favor this
option because some studies have shown that antibiotic
additives may weaken the polymer. Others have
expressed the concern that routinely using antibiotics in
this manner may contribute to increased drug resistance
of certain bacteria.'0
Cemented Total Hip Arthroplasty
Conventional cemented total hip arthroplasty dramat-
ically improves a patient's function and quality of life.
The original Charnley hip arthroplasty provided a good
to excellent clinical result in 80% to 85% of patients
observed for at least 15 to 20 years. The clinical failures,
such as symptomatic aseptic loosening leading to revi-
sion arthroplasty, occur at a rate of about 1 % per year of
follow-up. Radiographic loosening occurs at twice that
rate, affecting a third of hip recipients by 15 years." With
contemporary prostheses and modern cementing
techniques, the rate of femoral loosening appears to be
substantially reduced.'2 Regardless of the cementing
technique, mechanical loosening occurs more common-
ly in young, heavy, active men and with certain prosthet-
ic designs.
In patients with rheumatoid arthritis, the clinical fail-
ure rate of total hip arthroplasty, which may be as high
as 25% at 12 years, is generally higher than in those with
osteoarthritis. In patients with rheumatoid arthritis, the
incidence of delayed wound healing and sepsis may be
increased as well.'3 These patients tend to be younger
and to have osteoporosis. In patients with Paget's
disease, total hip arthoplasty is usually associated with a
satisfactory result, although excessive bleeding from
hypervascular bone may complicate the surgical proce-
dure. Total hip arthroplasty may be the only viable treat-
ment alternative in patients with advanced avascular
necrosis; some investigators have reported inferior long-
term results in these patients, presumably because of
their younger age and increased physical demands. In
patients with ankylosing spondylitis, total hip arthro-
plasty is associated with a higher incidence of hetero-
topic ossification; preexisting soft-tissue contractures
may limit hip motion postoperatively.
An important cause of clinical failure leading to
surgical revision in cemented total hip arthroplasty is
biologic loosening due to aggressive osteolysis.
246 WJM, March 1995-Vol 162, No. 3
Phagocytosis of metal, polyethylene, and acrylic wear-
debris particles by macrophages leads to localized
resorption of bone, with consequent loosening of the
prosthetic components. The process is characterized his-
tologically by the presence of macrophages, multinucle-
ated giant cells, and by intracellular particles of cement
and polyethylene. On radiographic examination, bone
resorption is seen as progressively enlarging lytic foci
around the prosthetic components. Mechanical loosen-
ing of the device ultimately occurs, occasionally with
further fragmentation of the cement surrounding the
components."4 Similar lytic bone resorption may take
place in cementless arthroplasties due to debris pro-
duced by wear of the femoral head against the polyeth-
ylene acetabular component.
Noncemented Total Hip Arthroplasty
Noncemented total hip arthroplasty was developed in
response to evidence that cement debris plays an impor-
tant role in promoting bone lysis and loosening.
Prosthetic devices have been developed that achieve fix-
ation without cement either by "press-fit" or by biologic
ingrowth. With the press-fit technique, stabilization is
achieved by interference fit of the implant into the femur.
With biologic ingrowth, fixation occurs by bone
ingrowth into a porous surface. Noncemented devices
are most frequently used in young patients with high
physical demands where a revision surgical procedure in
the future will be more likely. Preliminary data suggest
that noncemented total hip arthroplasties have a relative-
ly low revision rate and excellent prosthetic durability
for as long as 15 years. Compared with cemented hip
arthroplasties, however, patients have a higher incidence
of low-grade, temporary thigh pain. Although short-term
results appear to be less satisfactory compared with
cemented hip arthroplasty, after 5 to 20 years, the results
in the two procedures are similar.'5 As mentioned,
despite the absence of cement debris in noncemented
total hip arthroplasties, femoral osteolysis may still
occur in as many as 5% of patients as a result of the for-
mation of polyethylene wear debris. Noncemented total
hip arthroplasty, whether of the press-fit or biologic
ingrowth variety, requires a more exacting surgical inser-
tion technique than does cemented arthroplasty because
maximum contact between prosthesis and bone must be
achieved. Even in the best of circumstances, complete
contact may be difficult to achieve. Some manufacturers
have dealt with the problem by creating a variety of
implants to better match the various internal shapes and
sizes of different femurs. Unfortunately, this approach
creates a logistical and cost problem because of the large
inventory of implants that must be kept available.
The biologic ingrowth designs are now used exten-
sively. Studies of animals have shown excellent
ingrowth of bone into the porous surfaces of both cobalt-
chrome and titanium implants. One method used to
produce a porous ingrowth surface in cobalt-chrome
prostheses is to fuse metal beads 250 to 400 ,um in
Total Hip Arthroplasty-Siopack and jergesen
diameter onto the surface of implants. Small pores are
present between the beads. Studies have shown that bone
ingrowth into porous surfaces begins within the first 6 to
12 weeks after implantation.'6 Implant-retrieval studies
in humans have confirmed that ingrowth of bone and
fibrous tissue does occur. Even in prostheses shown ra-
diographically to be well fixed, however, a surprisingly
low percentage of available surface area is involved with
the ingrowth of bone. Despite concerns about how much
ingrowth actually takes place, clinical studies have
shown that some noncemented porous-ingrowth designs
are as successful as cemented implants.
Some investigators have cautioned that metal ion
release from the porous coating of the prosthesis may
cause an osteolytic reaction in adjacent bone.'7 Others
have suggested that bone fixation can be enhanced by
coating the implant with hydroxyapatite or tricalcium
phosphate, both of which closely resemble natural bone
mineral. These agents may further serve as a barrier to
elemental ion transfer from the prosthetic device into the
surrounding tissues.'8
Because early reports noted an increased rate of
acetabular loosening relative to femoral loosening in
cemented arthroplasties, the concept of the "hybrid"
total hip arthroplasty has been adopted by many sur-
geons. The hybrid total hip arthroplasty consists of a
cemented femoral stem and a noncemented acetabular
cup. Cementing the stem using contemporary techniques
allows earlier unrestricted weight bearing and yields a
lower incidence of low-grade thigh pain. Leaving the
acetabular component uncemented avoids the conse-
quences of cement fragmentation and loosening. In
many centers, hybrid total hip arthroplasty is now the
preferred technique for primary hip arthroplasty in
patients older than 60. Results in patients observed for
two to four years show that the hybrid arthroplasty per-
forms as well as cemented total hip arthroplasty in the
short term.'9
Operative Aspects
As with any major surgical procedure, cardiovascu-
lar, renal, and pulmonary function must be fully assessed
preoperatively in all patients undergoing total hip arthro-
plasty. The procedure may be done under regional as
well as general anesthesia, allowing patients with med-
ical contraindications to general anesthesia to undergo
it.2 Total hip arthroplasty is contraindicated if active
infection is present either locally in the pelvic region or
elsewhere in the body. The procedure may be performed
through various surgical approaches, and in all tech-
niques, scrupulous precautions are taken to prevent bac-
terial contamination of the open wound. Prophylactic
intravenous antibiotics are used routinely. To reduce the
chance of infection further, some surgeons advocate
added precautions such as operating in laminar-flow
enclosures with filtered air or wearing special hoods
designed to divert exhaled air from the operative field.
WJM, March 1995-Vol 162,
1995-Vl123-- No. 3
Early Complications
Fracture
The incidence of fracture is about 1%' and has been
reduced with the use of modem prostheses and contem-
porary surgical techniques. A greater incidence of
fractures (6%) occurs in revision arthroplasties with
noncemented prostheses. The femur is the most com-
mon site of fracture during both primary and revision
procedures. Fractures of the acetabulum and pubic rami
occur only rarely.
Nerve injury. Transient or permanent nerve injury
may occur with total hip arthroplasty. The most common
nerve injured is the sciatic, where the incidence is
reported to be about 0.7%.21 This is usually caused by
intraoperative trauma, but can also complicate postoper-
ative dislocation of the prosthesis. The prognosis for
nerve recovery is good unless the nerve is severely dam-
aged. Operative trauma results in less frequent injury to
the obturator, gluteal, and femoral nerves.
Dislocation. Dislocation of the femoral head compo-
nent out of the acetabular socket occurs in 1% to 3% of
primary total hip procedures. The main causes of dislo-
cation include inadequate patient compliance with post-
operative precautions and malposition of the prosthetic
components at the time of the operation. Dislocation is
second only to loosening as a cause of revision." The
most common technical error predisposing to disloca-
tion is malposition of the acetabular component. Most
dislocations occur within six months of the surgical pro-
cedure, and most patients may be managed conserva-
tively. Recurrent dislocations may require surgical
revision, however.
Deep vein thrombosis and pulmonary embolism.
Much attention has been paid to deep vein thrombosis
and pulmonary embolism as a leading cause of morbid-
ity and mortality in patients with total hip arthroplasty.
In the absence of prophylaxis, the incidence of deep vein
thrombosis may be as high as 70% and of pulmonary
embolism, 20%. Mortality from pulmonary embolism
has been reported to be as high as 2%.Y Routine pro-
phylaxis against deep vein thrombophlebitis is therefore
recommended in total hip arthroplasty. Graded-
compression elastic stockings and early mobilization are
used as minimum precautions. Various anticoagulation
regimens have been administered, but investigators do
not agree as to which is most effective. Low-dose
heparin is commonly used, but is reported to be of ques-
tionable benefit unless combined with antithrombin III.3
Low-dose warfarin is used in many centers; but many
surgeons are reluctant to accept the risk of bleeding
complications that may occur with this and other regi-
mens. Using regional anesthesia in total hip arthroplasty
is reported to decrease the incidence of deep venous
thrombosis and pulmonary embolism by as much as two
thirds when compared with general anesthesia.24
Because thromboembolism may occur despite prophy-
laxis, vigilance is necessary, and clinical suspicion of
Total Hip Arthroplasty-Siopack and lergesen
I Itoay Io 247
this complication may well prompt Doppler ultrasound
examination, leg venography, pulmonary scanning, or
pulmonary angiography.
Wound Complications
The most noteworthy wound complications in total
hip arthroplasty are hematoma and infection. The over-
all incidence of hematoma is 3.5%.2° Infection may
occur as a secondary complication because the
hematoma may act as a culture medium for bacteria.
Superficial wound infections are rare and must be dif-
ferentiated from deep infection involving the prosthetic
components themselves.
Late Complications
Infection
Most studies report an infection rate of 1% or less in
primary total hip arthroplasty. In revision arthroplasties
this rate is reported to be 3% or higher. Infections diag-
nosed within the first few weeks after the procedure or
as long as a year later are most likely due to periopera-
tive contamination.' This relatively low infection rate is
due in part to the routine use of prophylactic antibiotics
in the perioperative period. Antistaphylococcal drugs
such as vancomycin or one of the cephalosporins are
used most frequently for this purpose. The additional use
of ultraclean air enclosures may reduce infection rates to
lower than 1%. As noted earlier, another prophylactic
technique adopted by some surgeons is the direct addi-
tion of antibiotics to cement, which allows the drug to
elute into the adjacent tissue. Although some use this
technique routinely, others reserve its use for hips that
have been previously infected. By combining different
prophylactic strategies during total hip arthroplasty pro-
cedures, some report an incidence of deep infection as
low as 0.4%.26
Deep infection in total hip arthroplasty that presents
more than a year after the procedure may occur as the
result of hematogenous seeding of the implant by organ-
isms originating from a distant site. Infections of the
skin, urinary tract, gastrointestinal tract, and mouth are
most frequently implicated as sources. Because of this
phenomenon, patients who have undergone total hip
arthroplasty are counseled to seek rapid treatment of any
suspected bacterial infection. Routine prophylactic
antibiotic treatment is also recommended for any inva-
sive procedure that could result in a hematogenous
spread of bacteria.
Established deep infection in these cases has a ten-
dency to persist unless all prosthetic material is
removed, infected tissues are thoroughly debrided, and
appropriate antibiotic treatment is administered. Some
surgeons have advocated immediate reimplantation of
another prosthesis at the time of the initial debridement.
Most defer such revisions for 3 to 12 months, however,
and proceed only if the infection appears clinically qui-
escent. Subsequent hip aspirates must be culture-
negative before revision arthroplasty is attempted.
248 WJM, March 1995-Vol 162, No. 3
Heterotopic Ossification
Heterotopic ossification may occur in as many as
70% of patients undergoing total hip arthroplasty. The
incidence of this complication in its more severe and lim-
iting form is much less-only about 4%.27 When severe,
heterotopic ossification usually compromises range of
motion rather than producing pain. Patients at risk
include those with previous heterotopic bone formation
and those with diffuse idiopathic skeletal hyperostosis,
ankylosing spondylitis, or in men, hypertrophic
osteoarthritis. Prophylaxis with certain nonsteroidal anti-
inflammatory drugs or with postoperative low-dose radi-
ation therapy is effective for those patients who are at
risk. In the event that substantial ossification develops,
surgical excision may be helpful, but it is usually delayed
for a year to allow the ectopic bone to mature fully.
Loosening
Loosening is the most common cause of failure in
noninfected hip arthroplasties. It is manifested by
absorption of bone around the implant or cement and is
usually detected radiographically before the patient has
pain. Loosening may be mechanical or biologic in nature
and frequently occurs with long-standing infection.
Mechanical loosening results from loading that exceeds
the strength of either the prosthetic material or its inter-
face with bone. Excessive loading because of overuse,
poor prosthetic design, and improper insertion technique
may predispose to this problem. Biologic loosening
results from bone resorption mediated by cells stimulat-
ed by the presence of particulate-wear debris from
cement, polyethylene, or metal. Poor cementing tech-
nique, common in earlier years, has been implicated as a
cause of loosening. In one study, the incidence of asep-
tic loosening using first-generation cementing tech-
niques was 32% at 15-year follow-up, with a revision
rate of 12.7% as a consequence." More recent studies in
which newer, second-generation cementing techniques
have been used show reduced loosening rates.
Future Directions
Total hip arthroplasty is continuously evolving in
terms of materials, prosthetic design, surgical technique,
prevention of complications, and postoperative manage-
ment. The future of prosthetic hip design lies in the devel-
opment of new materials that will have acceptable bio-
compatibility and better physical properties, leading both
to better integration into bone and to better wear charac-
teristics. One direction in design research is the develop-
ment of an isoelastic prosthesis, which has physical prop-
erties similar to bone. To achieve this, some researchers
have experimented with composites of plastics and met-
als, elements that can confer flexibility and strength at the
same time.2' Research in the area of noncemented
ingrowth prostheses is focusing on designs that will per-
mit greater bony ingrowth to produce better short- and
long-term fixation. Finally, research is underway to iden-
tify better materials for the bearing surfaces of prosthetic
components to eliminate wear particle-induced osteolysis.
Total Hip Arthroplasty-Siopack and jergesen
Custom-made prostheses designed to improve indi-
vidual fit have received attention in recent years. The
goal of a precise prosthetic fit is to lower the incidence
of postoperative discomfort in noncemented total hip
arthroplasty and to provide better survival of the arthro-
plasty. Because of the high cost of materials and engi-
neering, economics will limit the development of these
types of devices. Improvements in technology may allow
custom implants to be produced more cheaply, however.
New limitations in health care reimbursement by
third-party payers are beginning to have an effect on the
economics of total hip arthroplasty. Most of the cost of
primary total hip arthroplasty is determined by the
length of a patient's hospital stay and by the cost of the
prosthetic implant. In our institution (University of
California, San Francisco, Medical Center), hospital
stays for primary total hip arthroplasty that used to range
from 10 to 14 days are now being reduced to 5 to 7 days.
Efforts are underway to reduce the cost of prosthetic
implants both by limiting the types of implants being
used and by reducing the unit cost of implants through
contracts with vendors based on volume use.
In an era in which increasing attention is being paid
to the relative benefits of medical services, outcome
studies are being undertaken to document the results of
procedures such as total hip arthroplasty. A prospective
study in Canada has shown conclusively, from a public
health perspective, that both cemented and uncemented
total hip arthroplasty are cost-effective and beneficial."
Similar studies will no doubt be required in this country,
both to assess results of new arthroplasty techniques and
to monitor the quality of care provided to patients with
total hip arthroplasty whose treatment is increasingly
affected by cost reduction policies.
REFERENCES
1. Pearcy MJ: A new generation of artificial hip joints. Eng Med 1988;
17:199-201
2. Petty W: Total Joint Replacement-§VI, Lower Extremity Replacement:
The Hip. Philadelphia, Pa, WB Saunders, 1991, pp 189-465
3. McKee GK, Watson-Farrar J: Replacement of arthritic hips by the McKee-
Farrar prosthesis. J Bone Joint Surg [Br] 1966; 48:245-259
4. Chamley J: Total hip replacement. JAMA 1974; 230:1025-1028
5. Charnley J: Low Friction Arthroplasty of the Hip: Theory and Practice.
Berlin, Germany, Springer-Verlag, 1979, pp 332-345
6. Morrey BF, Ilstrup DM: Size of the femoral head and acetabular revision
in total hip replacement arthroplasty. J Bone Joint Surg [Am] 1989; 71:50-55
7. Sullivan P, Scott K, Johnston R: Current concepts in hip joint replacement.
Iowa Med 1992; 276:468-469
8. Rose RM, Nusbaum HJ, Schneider H: On the true wear rate of ultra high
molecular weight polyethylene in the total hip prosthesis. J Bone Joint Surg
[Am] 1980; 62:537-549
9. Moreland JR: Primary total hip arthroplasty, chap 55, In Chapman MW
(Ed): Operative Orthopaedics, Vol 1. Philadelphia, Pa, Lippincott, 1988, pp 679-
693
10. Hope PG, Kristinsson KG, Norman P, Elson RA: Deep infection of
cemented total hip arthroplasties. J Bone Joint Surg [Br] 1989; 71:851-855
11. Welch RB, McGann WA, Picetti GD 3d: Charnley low-friction arthro-
plasty-A 15- to 17-year follow-up study. Orthop Clin North Am 1988; 19:551-
555
12. Russotti GM, Coventry MB, Stauffer RN: Cemented total hip arthro-
plasty with contemporary techniques. Clin Orthop 1988; 235:141-145
13. Severt R, Wood R, Cracchiolo A: Long-term follow-up of cemented total
hip arthroplasty. Clin Orthop 1991; 265:137-145
14. Maloney WJ, Jasty M, Rosenberg A: Bone lysis in well-fixed cemented
femoral components. J Bone Joint Surg [Br] 1990; 72:966-970
WJM, March 1995-Vol 162, No. 3
15. Cook SD, McCluskey LC, Martir PC: Inflammatory response in
retrieved noncemented porous-coated materials. Clin Orthop 1991; 264:209-222
16. Haddad RJ, Cook SD, Thomas KA: Biological fixation of porous-coated
implants. J Bone Joint Surg [Am] 1987; 69:1459-1466
17. Collier JP, Mayor MB, Chae JC: Macroscopic and microscopic evidence
of prosthetic fixation with porous-coated materials. Clin Orthop 1988; 235:173-
178
18. Thomas KA: Biomechanics and biomaterials of hip implants. Curr Opin
Orthop 1990; 1:28-37
19. Harris WH, Maloney WJ: Hybrid total hip arthroplasty. Clin Orthop
1989; 249:21-29
20. Rothman RH: Complications, chap 9, In Booth RE, Balderston RA,
Rothman RH (Eds): Total Hip Arthroplasty. Philadelphia, Pa, WB Saunders,
1988, pp 174-218
21. Weber ER, Daube JR, Coventry MB: Peripheral neuropathies associated
with total hip arthroplasty. J Bone Joint Surg [Am] 1976; 58:66-69
22. Haake DA, Berkman SA: Venous thromboembolic disease after hip
surgery-Risk factors, prophylaxis and diagnosis. Clin Orthop 1989; 242:212-
231
23. Francis CW, Pelligrini VD, Marder VJ: Prevention of venous thrombosis
after total hip arthroplasty. J Bone Joint Surg [Am] 1989; 71:327-335
Total Hip Arthroplasty-Siopack and jergesen 249
24. Wille-J0rgensen P, Christensen SW, Bjerg-Nielsen A, Stadaeger C, Kjaer
L: Prevention of thromboembolism following elective hip surgery-The value of
regional anesthesia and graded compression stockings. Clin Orthop 1989;
247:163-167
25. Wilson PD, Salvati EA, Aglieti P, Kukner LJ: The problem of infection
in endoprosthetic surgery of the hip joint. Clin Orthop 1973; 96:213-216
26. Schutzer SF, Harris WH: Deep-wound infection after total hip replace-
ment under contemporary aseptic conditions. J Bone Joint Surg [Am] 1988;
70:724-727
27. Brooker AF, Bowerman JW, Robinson RA, Riley LH: Ectopic ossifica-
tion following total hip replacement. J Bone Joint Surg [Am] 1973; 55:1629-
1632
28. Kavanagh BF, Deuritz MA, Ilstrup DM, Stauffer RN, Coventry MD:
Chamley total hip arthroplasty with cement. J Bone Joint Surg [Am] 1989;
71:1496-1503
29. McKee GK: THR-Past, present, future. Biomaterials 1990; 3:130-135
30. Boume RB, Rorabeck CH, Laupacis A: Cemented Versus Cementless
Total Hip Replacement-Cost Effectiveness and Its Impact on Health Related
Quality of Life. Presented at the Hip Society 21st scientific meeting, San
Francisco, Califomia, 1993